ACT with the Multi-Problem Patient

Abstract

Of the many types of presenting problems seen by mental health, chemical dependency and general health care providers, none is more challenging than the patient experiencing chronic mood disturbance, marginal social adaptation, high levels of interpersonal isolation, conflict and/or daily stress and, frequently, recurrent self-destructive behavior. These patients often receive a clinical diagnosis of “personality disorder,” but it is probably more appropriate to describe them as “multi-problem” patients because of wide spread deficiencies in their cognitive, emotional, behavioral and social functioning. Such patients typically experience chronic negative emotional states such as depression, anxiety, apathy, boredom, loneliness, guilt and anger. This affect is a major driver of a plethora of maladaptive coping responses: chief among them are repetitious suicidal behavior, and addictive behaviors such as alcohol/drug abuse, eating disorders and/or chronic self-mutilation. Multi-problem patients also experience significant difficulties in social and interpersonal functioning. They have trouble forming and maintaining interpersonal relationships and often inject the therapy process with a conflict-laden set of issues around forming and maintaining both casual and intimate adult relationships. The number and magnitude of these behavioral, cognitive and emotional problems is a source of frustration for therapists. It is hard to conceptualize a plan of action in therapy when, at any given point in time, the patient exhibits generalized failure in so many areas of functioning. Further, the disruptive presence of chronic suicidal ideation, suicide attempting and various other forms of self-destructive behavior disrupts the continuity of treatment and can severely challenge the therapeutic relationship.